Acute diverticulitis of the colon represents a significant burden for national health systems, in terms of direct and indirect costs. Past guidelines claimed that recurrent episodes (two or more) of diverticulitis need surgery, but revised guidelines recommend an individualized approach to patients after an attack of acute diverticulitis. For these reasons, conservative treatment has become the preferred choice after an episode of diverticulitis. Thus, significant efforts are now being focused to identify the correct therapeutic approach to prevent diverticulitis relapses. Nonabsorbable antibiotics, 5-aminosalicylic acid and probiotics are currently being investigated in this way. The effectiveness and the future perspectives of these treatments are discussed herein.
5-aminosalicylic acid; acute diverticulitis; high-fiber diet; nonabsorbable antibiotics; probiotics; recurrence
Sigmoid diverticulitis is a common benign condition which carries significant morbidity and socioeconomic burden. This article describes the management of sigmoid diverticulitis with a focus on indications for surgical intervention. The mainstay of management of uncomplicated diverticulitis is broad-spectrum antibiotic therapy. The old surgical dictum that two episodes of sigmoid diverticulitis warranted surgical intervention has been challenged by recently published data. Surgery for diverticulitis thus needs to be tailored to suit individual presentation; patients presenting with recurrent diverticulitis, severe symptoms or debilitating disease impacting patient’s quality of life mandate surgical intervention. Complicated diverticular disease typically prompts intervention to resect a diseased, strictured sigmoid colon, fistulizing disease, or a life-threatening colonic perforation. Laterally, minimally invasive surgery has been utilized in the management of this disease and recent data suggests that localized colonic perforation may be managed by laparoscopic peritoneal lavage, without resection. This review focuses discussion on available evidence for contemporary surgical and nonoperative management of diverticulitis.
sigmoid diverticulitis; colon; laparoscopic peritoneal lavage; surgical intervention
Diverticulosis is a common disease in the western society with an incidence of 33–66%. 10–25% of these patients will develop diverticulitis. In order to prevent a high-risk acute operation it is advised to perform elective sigmoid resection after two episodes of diverticulitis in the elderly patient or after one episode in the younger (< 50 years) patient. Open sigmoid resection is still the gold standard, but laparoscopic colon resections seem to have certain advantages over open procedures. On the other hand, a double blind investigation has never been performed. The Sigma-trial is designed to evaluate the presumed advantages of laparoscopic over open sigmoid resections in patients with symptomatic diverticulitis.
Indication for elective resection is one episode of diverticulitis in patients < 50 years and two episodes in patient > 50 years or in case of progressive abdominal complaints due to strictures caused by a previous episode of diverticulits. The diagnosis is confirmed by CT-scan, barium enema and/or coloscopy.
It is required that the participating surgeons have performed at least 15 laparoscopic and open sigmoid resections. Open resection is performed by median laparotomy, laparoscopic resection is approached by 4 or 5 cannula. Sigmoid and colon which contain serosal changes or induration are removed and a tension free anastomosis is created. After completion of either surgical procedure an opaque dressing will be used, covering from 10 cm above the umbilicus to the pubic bone. Surgery details will be kept separate from the patient's notes.
Primary endpoints are the postoperative morbidity and mortality. We divided morbidity in minor (e.g. wound infection), major (e.g. anastomotic leakage) and late (e.g. incisional hernias) complications, data will be collected during hospital stay and after six weeks and six months postoperative. Secondary endpoints are the operative and the postoperative recovery data. Operative data include duration of the operation, blood loss and conversion to laparotomy. Post operative recovery consists of return to normal diet, pain, analgesics, general health (SF-36 questionnaire) and duration of hospital stay.
The Sigma-trial is a prospective, multi-center, double-blind, randomized study to define the role of laparoscopic sigmoid resection in patients with symptomatic diverticulitis.
The exact pathogenesis of diverticular disease of the sigmoid colon is not well established. However, the hypothesis that a low-fibre diet may result in diverticulosis and a high-fibre diet will prevent symptoms or complications of diverticular disease is widely accepted. The aim of this review is to assess whether a high-fibre diet can improve symptoms and/or prevent complications of diverticular disease of the sigmoid colon and/or prevent recurrent diverticulitis after a primary episode.
Clinical studies were eligible for inclusion if they assessed the treatment of diverticular disease or the prevention of recurrent diverticulitis with a high-fibre diet. The following exclusion criteria were used for study selection: studies without comparison of the patient group with a control group.
No studies concerning prevention of recurrent diverticulitis with a high-fibre diet met our inclusion criteria. Three randomised controlled trials (RCT) and one case–control study were included in this systematic review. One RCT of moderate quality showed no difference in the primary endpoints. A second RCT of moderate quality and the case–control study found a significant difference in favour of a high-fibre diet in the treatment of symptomatic diverticular disease. The third RCT of moderate quality found a significant difference in favour of methylcellulose (fibre supplement). This study also showed a placebo effect.
High-quality evidence for a high-fibre diet in the treatment of diverticular disease is lacking, and most recommendations are based on inconsistent level 2 and mostly level 3 evidence. Nevertheless, high-fibre diet is still recommended in several guidelines.
High-fibre dietary therapy; Diverticular disease; Sigmoid colon
The aim of this study was to examine the relationship of complications related to diverticulitis and visceral obesity. The study was based on a retrospective case note review conducted at the Hanyang University Hospital. Patients were diagnosed with diverticulitis based on clinical symptoms and abdominal computed tomography (CT) findings and divided into two groups: those admitted with complicated diverticulitis and those with a simple diverticulitis episode. We compared the body mass index (BMI) and degree of visceral obesity, measured by abdominal CT. The study included 140 patients, 87 (62.1%) were simple diverticulitis and 53 (37.9%) were complicated diverticulitis. In the complicated diverticulitis group, 9 (6.4%) cases were recurrent, 29 (20.7%) were perforation or abscess patients, and 28 (20%) were patients with systemic inflammatory response syndrome (SIRS). Of the SIRS patients, 13 were involved in other complication groups. When comparing in the two groups, the complicated diverticulitis group had a significantly higher visceral fat area (128.57 cm2 vs 102.80 cm2, P = 0.032) and a higher ratio of visceral fat area/subcutaneous fat area (0.997 vs 0.799, P = 0.014). Visceral obesity is significantly associated with complications of diverticulitis.
Diverticulitis; Complications; Obesity; Visceral Obesity
Diverticular disease is a common problem in Western countries. Rationale for elective surgery is to prevent recurrent complicated diverticulitis and to reduce emergency procedures. Recurrent diverticulitis occurs in about 10% after resection. The pathogenesis for recurrence is not completely understood. We studied the incidence and risk factors for recurrence and the overall morbidity and mortality of surgical therapy for diverticular disease.
Medical records of 183 consecutive patients with pathology-proven diverticulitis were eligible for evaluation. Mean duration of follow-up was 7.2 years. Number of preoperative episodes, emergency or elective surgeries, type of operation, level of anastomosis, postoperative complications, persistent postoperative pain, complications associated with colostomy reversal, and recurrent diverticulitis were noted. The Kaplan-Meier method was used to calculate the cumulative probability of recurrence. Cox regression was used to identify possible risk factors for recurrence.
The incidence of recurrence was 8.7%, with an estimated risk of recurrence over a 15-year period of 16%. Risk factors associated with recurrence were (younger) age (p < 0.02) and the persistence of postoperative pain (p < 0.005). Persistent abdominal pain after surgery was present in 22%. Eighty percent of patients who needed emergency surgery for acute diverticulitis had no manifestation of diverticular disease prior to surgery. In addition, recurrent diverticulitis was not associated with a higher percentage of emergency procedures.
Estimated risk of recurrence is high and abdominal complaints after surgical therapy for diverticulitis are frequent. Younger age and persistence of postoperative symptoms predict recurrent diverticulitis after resection. The clinical implication of these findings needs further investigation. The results of this study support the careful selection of patients for surgery for diverticulitis.
Acute diverticulitis of the colon represents a significant burden for national health systems, in terms of direct and indirect costs. Although current guidelines recommend use of antibiotics for the outpatient treatment of acute uncomplicated diverticulitis, evidence for this is still lacking. Hence, significant effort is now being made to identify the appropriate therapeutic approach to treat and prevent relapses of diverticulitis. Outpatient treatment has been identified as a safe and effective therapeutic approach in up to 90% of patients with uncomplicated diverticulitis. It allows important costs saving to health systems without a negative influence on quality of life for patients with uncomplicated diverticulitis, and reduces health care costs by more than 60%.
diverticulitis; 5-aminosalycilic acid; antibiotics; probiotics; outpatient treatment
Microencapsulated sodium butyrate (MSB) has been previously associated with anti-inflammatory and regenerative properties regarding large bowel mucosa. We aimed to examine a role of MSB in patients with diverticulosis, hypothesizing its potential for reduction of diverticulitis episodes and diverticulitis prevention.
Seventy-three patients with diverticulosis (diagnosed in colonoscopy or/and barium enema or/and CT colography) were recruited for the study and randomized. The investigated group was administered MSB 300 mg daily; the control group was administered placebo. After 12 months, a total of 52 patients completed the study and were subject to analysis (30 subjects and 22 controls). During the study, the number of episodes of diverticulitis (symptomatic diagnosis with acute pain, fever, and leukocytosis), hospitalizations, and surgery performed for diverticulitis were recorded. Additionally, a question regarding subjective improvement of symptoms reflected changes in quality of life during the analysis.
After 12 months, the study group noted a significantly decreased number of diverticulitis episodes in comparison to the control group. The subjective quality of life in the study group was higher than in the control group. There were no side effects of the MSB during the therapy.
MSB reduces the frequency of diverticulitis episodes, is safe, and improves the quality of life. It can play a role in the prevention of diverticulitis.
Sodium butyrate; Diverticulitis; Diverticulosis; Prevention
Sigmoid diverticulitis is a common disease which carries both a significant morbidity and a societal economic burden. This review article analyzes the current data regarding management of sigmoid diverticulitis in its variable clinical presentations. Wide-spectrum antibiotics are the standard of care for uncomplicated diverticulitis. Recently published data indicate that sigmoid diverticulitis does not mandate surgical management after the second episode of uncomplicated disease as previously recommended. Rather, a more individualized approach, taking into account frequency, severity of the attacks and their impact on quality of life, should guide the indication for surgery. On the other hand, complicated diverticular disease still requires surgical treatment in patients with acceptable comorbidity risk and remains a life-threatening condition in the case of free peritoneal perforation. Laparoscopic surgery is increasingly accepted as the surgical approach of choice for most presentations of the disease and has also been proposed in the treatment of generalized peritonitis. There is not sufficient evidence supporting any changes in the approach to management in younger patients. Conversely, the available evidence suggests that surgery should be indicated after one attack of uncomplicated disease in immunocompromised individuals. Uncommon clinical presentations of sigmoid diverticulitis and their possible association with inflammatory bowel disease are also discussed.
Sigmoid diverticulitis; Diverticulitis management; Diverticulitis surgery; Acute diverticulitis; Complicated diverticulitis; Perforated diverticulitis; Laparoscopic colectomy
A 59-year-old man presented with abdominal and left flank pain. The symptom had started 30 days before as an acute nephrolithiasis, which had worsened despite conservative management. The abdomen was slightly distended and tender over the lower abdomen, without signs of generalized peritoneal irritation. A computed tomography (CT) scan showed an abscess in left para-renal space up to the subphrenic space and an unexpected pneumomediastinum. An emergency operation was performed, which showed retroperitoneal diverticulitis perforation of the sigmoid descending junction with abscess formation. A segmental resection of the diseased colon and end-colostomy was performed (Hartmann's procedure). However, the patient's condition progressively deteriorated, and he died of sepsis and multi-organ failure on the 5th postoperative day. Although pneumomediastinum caused by colonic diverticulitis perforation is extremely rare, it could be a life-threatening condition in patients without signs of peritonitis because of delayed diagnosis.
Pneumomediastinum; Diagnostic; Diverticulitis; Colonic; Perforation
Mechanical bowel preparation (MBP) has been shown to have no influence on the incidence of anastomotic leakage in overall colorectal surgery. The role of MBP in elective surgery in combination with an inflammatory component such as diverticulitis is yet unclear. This study evaluates the effects of MBP on anastomotic leakage and other septic complications in 190 patients who underwent elective surgery for colonic diverticulitis.
A subgroup analysis was performed in a prior multicenter (13 hospitals) randomized trial comparing clinical outcome of MBP versus no MBP in elective colorectal surgery. Primary endpoint was the occurrence of anastomotic leakage in patients operated on for diverticulitis, and secondary endpoints were septic complications and mortality.
Out of a total of 1,354 patients, 190 underwent elective colorectal surgery (resection with primary anastomosis) for (recurrent or stenotic) diverticulitis. One hundred and three patients underwent MBP prior to surgery and 87 did not. Anastomotic leakage occurred in 7.8 % of patients treated with MBP and in 5.7 % of patients not treated with MBP (p = 0.79). There were no significant differences between the groups in septic complications and mortality.
Mechanical bowel preparation has no influence on the incidence of anastomotic leakage, or other septic complications, and may be safely omitted in case of elective colorectal surgery for diverticulitis.
Colonic diverticulitis; Mechanical bowel preparation; Anastomotic leak; Surgical site infection
Autosomal dominant hyperimmunoglobulin E syndrome (HIES, Job syndrome) is a rare primary immunodeficiency characterized by elevated immunoglobulin E (IgE), eosinophilia, recurrent skin and pulmonary infections, dermatitis, and connective tissue and skeletal abnormalities. A 26-year-old male with known HIES presented with abdominal pain and diarrhea. Imaging showed sigmoid diverticulitis without abscess or perforation. Conservative management with antibiotics failed, and he developed a peridiverticular abscess, which was percutaneously drained with plans for elective resection. He returned four days later with progression of his diverticulitis, requiring partial colectomy with primary anastomosis. To our knowledge, this is the first case of diverticulitis in HIES. Diverticulitis is rare in younger individuals, raising the possibility that the connective tissue abnormalities of HIES patients may predispose them to colonic diverticula. Although the majority of complications are sinopulmonary and skin infections, diverticulitis should be considered in the differential of intra-abdominal processes in HIES.
Hyper IgE Syndrome; diverticulitis
AIM: To identify patients with persistent acute diverticulitis who might benefit from an early colonoscopy during their first hospitalization.
METHODS: All patients hospitalized between July 2000 and December 2006 for acute diverticulitis who underwent colonoscopy were included in the study. Patients were followed during hospitalization and after discharge. Patients were considered to have a persistent course of acute diverticulitis if symptoms continued after 1 wk of conventional treatment with IV antibiotics, or if symptoms recurred within 2 mo after discharge. Patients were considered to benefit from an early colonoscopy if the colonoscopy was therapeutic or if it changed a patient's outcome.
RESULTS: Three hundred and six patients were hospitalized between July 2000 and December 2006 with the diagnosis of acute diverticulitis. Two hundred and twenty four of these were included in the study group. Twenty three patients (10.3%) fulfilled the criteria for a persistent course of acute diverticulitis. Of them, four patients (17.4%) clearly benefited from an early colonoscopy; these patients’ clinical course is described. None of the patients with a regular non-persistent course demonstrated any benefit from colonoscopy.
CONCLUSION: Early colonoscopy detected other significant pathology, which accounted for the clinical presentation in 17% of patients with persistent acute diverticulitis. Therefore, we believe an early colonoscopy should be considered in all patients with a persistent clinical course.
Persistent acute diverticulitis; Early colonoscopy; Clinical course
Perforated diverticulitis is a condition associated with substantial morbidity. Recently published reports suggest that laparoscopic lavage has fewer complications and shorter hospital stay. So far no randomised study has published any results.
DILALA is a Scandinavian, randomised trial, comparing laparoscopic lavage (LL) to the traditional Hartmann's Procedure (HP). Primary endpoint is the number of re-operations within 12 months. Secondary endpoints consist of mortality, quality of life (QoL), re-admission, health economy assessment and permanent stoma. Patients are included when surgery is required. A laparoscopy is performed and if Hinchey grade III is diagnosed the patient is included and randomised 1:1, to either LL or HP. Patients undergoing LL receive > 3L of saline intraperitoneally, placement of pelvic drain and continued antibiotics. Follow-up is scheduled 6-12 weeks, 6 months and 12 months. A QoL-form is filled out on discharge, 6- and 12 months. Inclusion is set to 80 patients (40+40).
HP is associated with a high rate of complication. Not only does the primary operation entail complications, but also subsequent surgery is associated with a high morbidity. Thus the combined risk of treatment for the patient is high. The aim of the DILALA trial is to evaluate if laparoscopic lavage is a safe, minimally invasive method for patients with perforated diverticulitis Hinchey grade III, resulting in fewer re-operations, decreased morbidity, mortality, costs and increased quality of life.
British registry (ISRCTN) for clinical trials ISRCTN82208287http://www.controlled-trials.com/ISRCTN82208287
Elective surgical resection in cases of diverticulitis should be offered to patients who have experienced two episodes. High-risk patients such as immunocompromised individuals or transplant patients may warrant resection after one episode. It is controversial whether young patients or patients with right-sided diverticulitis need to be treated differently. Chronic diverticulitis can be successfully treated surgically in selected cases. Adequate surgical resection margins should include the top of the true rectum and the proximal extent of thickened inflamed colon to minimize the risk of recurrence. Careful operative planning and the use of proximal diversion if unsuspected significant inflammatory changes are encountered will improve surgical outcomes.
Diverticular disease; elective surgery; right-sided diverticulitis; patient selection; temporary diversion
A 58-year-old woman presented to the emergency department with cauda equina syndrome and sepsis. The symptoms were attributed to a complicated episode of sigmoid diverticulitis. MRI showed that the diverticulitis had caused an intra-abdominal fistula to a presacrally localized abscess expanding into the spinal canal, compressing the cauda equina nerves. Although Hartmann's procedure was performed, the neurological symptoms persisted, causing the patient to remain partially paraplegic. This case report illustrates that cauda equina syndrome is a condition that can also be caused by intra-abdominal pathology such as diverticulitis.
Complicated diverticulitis; Colonic diverticulitis; Sigmoid; Fistula; Cauda equina syndrome
Colocutaneous fistula caused by diverticulitis is relatively rare, and a delayed recrudescent case of colocutaneous fistula is very uncommon. We herein report a rare case of a Japanese 56-year-old male with delayed recrudescent sigmoidocutaneous fistula due to diverticulitis. A colocutaneous fistula was formed after a drainage operation against a perforation of the sigmoid colon diverticulum. After 5 years from treatment, he was admitted to our hospital because of lower abdominal pain. We diagnosed the recrudescent sigmoidocutaneous fistula by abdominal computed tomography and gastrografin enema, and managed the patient with total parenteral nutrition and antibiotics. As the fistula formation did not improve, a low anterior resection with fistulectomy was performed. The postoperative course was uneventful and the patient was discharged. It has been reported that, in fistulas of the skin caused by diverticular disease, complete closure of the fistula by conservative therapy may not be possible. This case also implies the possibility of a recurrence of the fistula even if the conservative treatment was effective. In cases of colocutaneous fistulas due to diverticulitis, radical surgery is considered necessary because of possibility of recurrence of the fistula.
Colocutaneous fistula; Diverticular disease; Diverticulitis
Conservative treatment of uncomplicated or mild diverticulitis usually includes antibiotic therapy. It is, however, uncertain whether patients with acute diverticulitis indeed benefit from antibiotics. In most guidelines issued by professional organizations antibiotics are considered mandatory in the treatment of mild diverticulitis. This advice lacks evidence and is merely based on experts' opinion. Adverse effects of the use of antibiotics are well known, including allergic reactions, development of bacterial resistance to antibiotics and other side-effects.
A randomized multicenter pragmatic clinical trial comparing two treatment strategies for uncomplicated acute diverticulitis. I) A conservative strategy with antibiotics: hospital admission, supportive measures and at least 48 hours of intravenous antibiotics which subsequently are switched to oral, if tolerated (for a total duration of antibiotic treatment of 10 days). II) A liberal strategy without antibiotics: admission only if needed on clinical grounds, supportive measures only. Patients are eligible for inclusion if they have a diagnosis of acute uncomplicated diverticulitis as demonstrated by radiological imaging. Only patients with stages 1a and 1b according to Hinchey's classification or "mild" diverticulitis according to the Ambrosetti criteria are included. The primary endpoint is time-to-full recovery within a 6-month follow-up period. Full recovery is defined as being discharged from the hospital, with a return to pre-illness activities, and VAS score below 4 without the use of daily pain medication. Secondary endpoints are proportion of patients who develop complicated diverticulitis requiring surgery or non-surgical intervention, morbidity, costs, health-related quality of life, readmission rate and acute diverticulitis recurrence rate. In a non-inferiority design 264 patients are needed in each study arm to detect a difference in time-to-full recovery of 5 days or more with a power of 85% and a confidence level of 95%. With an estimated one percent of patients lost to follow up, a total of 533 patients will be included.
A clinically relevant difference of more than 5 days in time-to-full recovery between the two treatment strategies is not expected. The liberal strategy without antibiotics and without the strict requirement for hospital admission is anticipated to be more a more cost-effective approach.
Trial registration number: NCT01111253
Colonic diverticulitis is an uncommon disease in Korea, but the incidence of the disease is increasing. The right colon is the more preferred site for diverticulitis in Korea, but the incidence of left diverticulitis is increasing. Therefore, comparing the clinical features and treatments for right diverticulitis with those for left diverticulitis may help us to treat the disease more properly.
This study was performed retrospectively by reviewing the medical records of 96 patients with colonic diverticulitis, in whom either conservative or operative treatments were performed.
Eighty-six patients had right diverticulitis (RD), and 10 patients had left diverticulitis (LD). The mean age of the patients was older for LD. Sixteen patients (18.6%) with RD had complications, and 7 patients (8.1%) underwent operations. On the other hand, 4 patients (40%) with LD had complications, and 3 patients (30%) underwent operations. The rates of complications and operations among old-aged patients were higher. The operations for 7 patients with RD who underwent surgery were 6 ileocecectomies and 1 diverticulectomy. On the other hand, the operations for the 3 patients with LD who underwent surgery were 2 resections and anastomoses and 1 diverticulectomy. The reasons for the operations were abscess formation, recurrence, perforation, and development of generalized peritonitis without response to conservative treatment.
The incidence of LD is lower than that of RD in Korea, but the rate of complications and operations seems higher in LD. Therefore, patients who complain of left lower abdominal pain need to be thoroughly examined for LD.
Diverticulitis is a debilitating complication of diverticular disease that affects approximately 2.5 million individuals in the United States. Compared to many other gastrointestinal conditions, diverticular disease is poorly understood in terms of its burden on patients and healthcare systems. This review examines the existing literature and discusses the current knowledge of the burden of diverticular disease. Literature confirmed that bothersome symptoms (such as abdominal pain and bloating) and potentially serious, disease-related complications (such as diverticulitis and diverticular bleeding) place a significant burden on patients. Broad-spectrum antibiotic therapy and surgery are the generally accepted mainstays of treatment for acute complications of diverticular disease. Despite these options, patients frequently experience substantially reduced quality of life (particularly in terms of social and emotional functioning) and increased mortality (predominantly due to disease-related complications) compared to healthy controls. Furthermore, diverticular disease accounted for 254,179 inpatient discharges and 1,493,865 outpatient clinic visits in the United States in 2002, at an estimated cost per hospitalization of $9,742-$11,729. Enhancing the quality of life of patients with diverticular disease and reducing disease exacerbations and complications will substantially benefit patients and healthcare systems. However, long-established treatment algorithms fall short of these therapeutic goals. Research into new treatment options for patients with diverticular disease should therefore be pursued.
Diverticular disease; quality of life; disease burden; healthcare costs
AIM: To study and provide data on the evolution of medical procedures and outcomes of patients suffering from perforated midgut diverticulitis.
METHODS: Three data sources were used: the Medline and Google search engines were searched for case reports on one or more patients treated for perforated midgut diverticulitis (Meckel’s diverticulitis excluded) that were published after 1995. The inclusion criterion was sufficient individual patient data in the article. Both indexed and non-indexed journals were used. Patients treated for perforated midgut diverticulitis at Vestfold Hospital were included in this group. Data on symptoms, laboratory and radiology results, treatment modalities, surgical access, procedures, complications and outcomes were collected. The Norwegian patient registry was searched to find patients operated upon for midgut diverticulitis from 1999 to 2007. The data collected were age, sex, mode of access, surgical procedure performed and number of patients per year. Historical controls were retrieved from an article published in 1995 containing pertinent individual patient data. Statistical analysis was done with SPSS software.
RESULTS: Group I: 106 patients (48 men) were found. Mean age was 72.2 ± 13.1 years (mean ± SD). Age or sex had no impact on outcomes (P = 0.057 and P = 0.771, respectively). Preoperative assessment was plain radiography in 53.3% or computed tomography (CT) in 76.1%. Correct diagnosis was made in 77.1% with CT, 5.6% without (P = 0.001). Duration of symptoms before hospitalization was 3.6 d (range: 1-35 d), but longer duration was not associated with poor outcome (P = 0.748). Eighty-six point eight percent of patients underwent surgery, 92.4% of these through open access where 90.1% had bowel resection. Complications occurred in 19.2% of patients and 16.3% underwent reoperation. Distance from perforation to Treitz ligament was 41.7 ± 28.1 cm. At surgery, no peritonitis was found in 29.7% of patients, local peritonitis in 47.5%, and diffuse peritonitis in 22.8%. Peritonitis grade correlated with the reoperation rate (r = 0.43). Conservatively treated patients had similar hospital length of stay as operated patients (10.6 ± 8.3 d vs 10.7 ± 7.9 d, respectively). Age correlated with hospital stay (r = 0.46). No difference in outcomes for operated or nonoperated patients was found (P = 0.814). Group II: 113 patients (57 men). Mean age 67.6 ± 16.4 years (range: 21-96 years). Mean age for men was 61.3 ± 16.2 years, and 74.7 ± 12.5 years for women (P = 0.001). Number of procedures per year was 11.2 ± 0.9, and bowel resection was performed in 82.3% of patients. Group III: 47 patients (21 men). Patient age was 65.4 ± 14.4 years. Mean age for men was 61.5 ± 17.3 years and 65.3 ± 14.4 years for women. Duration of symptoms before hospitalization was 6.9 d (range: 1-180 d). No patients had a preoperative diagnosis, 97.9% of patients underwent surgery, and 78.3% had multiple diverticula. Bowel resection was performed in 67.4% of patients, and suture closure in 32.6%. Mortality was 23.4%. There was no difference in length of history or its impact on survival between Groups I and III (P = 0.241 and P = 0.198, respectively). Resection was more often performed in Group I (P = 0.01). Mortality was higher in Group III (P = 0.002).
CONCLUSION: In cases with contained perforation, conservative treatment gives satisfactory results, laparoscopy with lavage and drainage can be attempted and continued with a conservative course.
Intestinal; Small bowel; Jejunum; Ileum; Perforation; Diverticulitis; Conservative treatment
AIM: To compare the natural history and course of acute diverticulitis in a younger age group with an older population and to evaluate whether younger patients should be managed differently.
METHODS: This study was a retrospective review of 157 patients treated with acute diverticulitis between January 1, 2004 and December 31, 2007. Diverticulitis was stratified according to the Hinchey classification. Patients were divided into 2 populations: group A ≤ 50 years (n = 31); group B > 50 years (n = 126). Mean patient follow-up was 15 mo.
RESULTS: The median age was 60 years. A significantly higher proportion of patients in group B presented with complicated diverticulitis (36.5% vs 12.9%, P = 0.01). Recurrence was more frequent in group A (25.8% vs 11.1%, P = 0.03) and the mean time-to-recurrence was shorter (12 mo vs 28 mo, P = 0.26). The most severe recurrent episodes of acute diverticulitis were classified as Hinchey stage I and none of the patients required emergency surgery. In multivariate analysis, only age (P = 0.024) was identified as an independent prognostic factor for recurrence.
CONCLUSION: Based on the results of this study, the authors recommend that diverticulitis management should be based on the severity of the disease and not on the age of the patient.
Acute diverticulitis; Recurrence; Age factors; Severity; Surgical treatment
Results of this study suggest that laparoscopic surgery for diverticular disease is a safe, feasible, and effective management strategy.
Surgical treatment of complicated colonic diverticular disease is still debatable. The aim of this prospective study was to evaluate the outcome of laparoscopic sigmoid colectomy in patients with diverticulitis. Patients offered laparoscopic surgery presented with acute complicated diverticulitis (Hinchey type I, II, III), chronically recurrent diverticulitis, bleeding, or sigmoid stenosis caused by chronic diverticulitis.
All patients who underwent laparoscopic colectomy within a 12-year period were prospectively entered into a database registry. One-stage laparoscopic resection and primary anastomosis constituted the planned procedure. A 4-trocar approach with suprapubic minilaparotomy was performed. Main data recorded were age, sex, postoperative pain, return of bowel function, operation time, duration of hospital stay, and early and late complications.
During the study period, 260 sigmoid colectomies were performed for diverticulitis. The cohort included 104 male and 156 female patients; M to F ratio was 4:6. Postoperative pain was controlled by NSAIDs or weak opioid analgesia. Fifteen patients (5.7%) required conversion from laparoscopic to open colectomy. The most common reasons for conversion were directly related to the inflammatory process, abscess, and peritonitis. Mean operative time was 130±54. Average postoperative hospital stay was 10±3 days. A longer hospital stay was recorded for Hinchey type IIb patients. Complications were recorded in 30 patients (11.5%). The most common complications that required reoperation were hemorrhage in 2 patients (0.76) and anastomotic leak in 5 patients (only 3 of them required reoperation). The mortality among them was 2 patients (0.76%).
Laparoscopic surgery for diverticular disease is safe, feasible, and effective. Therefore, laparoscopic colectomy has replaced open resection as standard surgery for recurrent and complicated diverticulitis at our institution.
Sigmoid diverticulitis; Laparoscopic surgery; Hinchey classification; Colectomy
The purpose of this study is to evaluate the value of nonoperative treatment for right-sided colonic diverticulitis.
One hundred fifty-eight patients with right-sided colonic diverticulitis were evaluated. Clinical history, physical and radiologic findings, and treatments were reviewed retrospectively. Also, additional episodes and treatment modalities were checked.
Our patients were classified according to treatment modality; 135 patients (85.4%) underwent conservative treatment, including antibiotics and bowel rest, and 23 patients (14.6%) underwent surgery. The mean follow-up length was 37.3 months, and 17 patients (17.5%) underwent recurrent right-sided colonic diverticulitis. Based on treatment modality, including surgery and antibiotics, no significant differences in the clinical features and the recurrence rates were noted between the two groups.
Conservative management with bowel rest and antibiotics could be considered as a safe and effective option for treating right-sided colonic diverticulitis. This treatment option for right-sided colonic diverticulitis, even if the disease is complicated, may be the treatment of choice.
Diverticulitis; Colonic diverticulitis; Drug therapy
Diverticulitis of vermiform appendix is known as a rare cause of acute appendicitis, most of which are diagnosed after surgery. We compared appendiceal diverticulitis with acute appendicitis to study the clinical characteristics of appendiceal diverticulitis.
Among 1,029 patients who received appendectomy from January 2009 to May 2011, 38 patients with appendiceal diverticulitis (diverticulitis group) were compared with 98 randomly collected patients with acute appendicitis (appendicitis group) during the same period. Patients' characteristics, clinical features, laboratory findings, operative findings, and postoperative course were compared between the two groups.
Thirty-eight patients (3.7%) were pathologically diagnosed with acute appendiceal diverticulitis among 1,029 cases of appendectomy. The mean age of patients in the diverticulitis group was significantly older than that of the appendicitis group (49.0 ± 15.2 years vs. 25.4 ± 14.2 years, P < 0.05). Mean duration of preoperative symptoms was longer in the diverticulitis group (3.6 ± 3.8 days vs. 1.8 ± 3.2 days, P < 0.05). The site of abdominal pain, fever, signs of localized peritonitis, accompanying gastrointestinal symptoms, and white blood cell count showed no differences between the two groups. Twenty-five patients (65.8%) of the diverticulitis group and 10 patients (10.2%) of the appendicitis group showed perforation of appendix (P < 0.05). Mean operating time and postoperative hospital stay were longer in the diverticulitis group (55.3 ± 28.8 minutes vs. 41.4 ± 17.8 minutes, 6.8 ± 3.4 days vs. 4.9 ± 1.5 days, P < 0.05).
Acute diverticulitis of the appendix can be classified into quite different disease entities compared with acute appendicitis. Regarding high rates of perforation, immediate surgical treatment is needed for patients with a high index of suspicion of acute diverticulitis of the appendix.
Appendiceal diverticulitis; Appendix; Diverticulitis; Appendicitis